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Dr. Reyesis the vice chief of staff and the assistant medical director of emergency medicine at Los Robles Hospital and Medical Center in Thousand Oaks, CA. He is also a clinical professor of pediatrics and emergency medicine at Olive View/UCLA Medical Center, a health law attorney with Boyce Schaeffer, LLP, in Oxnard, CA, and a founder and the CEO ofhealthelaw.com, which provides medical-legal education for doctors starting in medical school, through residency training, and beyond.

The days of paternal medicine are over. Back in the day, physicians held enormous power over patients. Patients rarely questioned a physician's recommendations, let alone his credentials. But now it seems the pendulum has swung too far in the other direction.

I get vexed when I deny a presumed narcotic-seeking patient another pain shot while I rule out his kidney stone, and he responds by asking to speak to an administrator. I could be wrong. My patient might have a kidney stone this time, despite the 15 prior negative CT scans and the long list of non-narcotic allergies. And to think, this patient may fill out a patient satisfaction survey to critique my care! Some colleagues, feeling the same frustration, admit to succumbing to narcotic demands to prevent the complaint to administration or low satisfaction score. But achieving consistently high scores involves much more than ordering an IV narcotic, as I discussed last month. (See FastLinks.)

The camp against patient satisfaction surveys would likely cite a recent study finding that focusing on patient satisfaction may be bad for patients. Fenton et al, in a multicenter prospective cohort study, found that the 51,946 respondents in the highest patient satisfaction quartile had more inpatient admissions, greater health care expenditures, and higher mortality than the lowest patient satisfaction quartile. (Arch Intern Med 2012;172[5]:405.) This study, however, cannot mean that a dissatisfied patient is a healthier patient. What this study may actually suggest is that physicians should not focus solely on patient satisfaction scores while treating patients.

Patient satisfaction scores are unsettling to some physicians because we are being graded. Physicians don't want to be graded by a patient survey for the same reason teachers don't want to be graded by their students' performance and hospitals don't want to be graded by their 30-day readmission rates. But instead of denying the validity of a patient satisfaction survey, physicians should try to understand why physicians sometimes get poor scores. Doing so will improve physician-patient interactions, lower malpractice risk, and secure ED contracts.

The Good

Improving physician-patient interactions raises satisfaction. Patients who are satisfied with their emergency physician's care perceive treatment success, even in the face of complications. ACEP's Patient Satisfaction Information Paper identified several benefits to improved patient satisfaction. (See FastLinks.) Patients who are satisfied with their emergency physician trust the physician's recommendations, and are compliant with the treatment plan. Satisfied patients also improve the morale and overall work satisfaction of physicians and hospital staff, and emphasizing all the drivers of patient satisfaction (timeliness, empathy, technical competence, information, and pain management) improves the quality of delivery of ED care. (Am J Med Qual 2010 25[1]:64.) Merely focusing on pain management without keeping patients informed during an ED visit or demonstrating physician competency will not achieve long-lasting patient satisfaction benchmarks.

Implementing processes to improve patient satisfaction scores is an important albeit difficult task. The first step is to recognize the problem. Low satisfaction scores may have several root causes: a physician with an inappropriate verbal tic, a nurse who missed her calling as a trauma surgeon, or an x-ray tech with lead feet. Failure to identify the root cause of a low score leads to the default position of blame, the emergency physician, because patients have the misperception that emergency physicians have full control of everything that happens in the ED. A patient satisfaction survey that identifies that the emergency physician wasn't the problem speaks volumes to administration about the real problems in the ED.

The Bad

Improving satisfaction scores reduces malpractice risk. The second step is to create a process that reliably collects the data. A colleague of mine has a saying about bad data, “garbage in, garbage out.” Press Ganey, the largest patient satisfaction survey vendor, admits that physician surveys are statistically insignificant unless at least 30-50 surveys are collected per physician, and yet they submit a physician score after accumulating only seven surveys.

In fact, at least 175-225 surveys would have to be collected to achieve a 95% confidence interval. One solution is to conduct a real-time survey for all discharged ED patients or email the survey upon discharge. One study demonstrated impressive improvement in satisfaction scores at a hospital that implemented a real-time survey. (Ann Emerg Med 2011;58[4S]:S181.)

The Ugly

Increasing patient satisfaction scores will save the hospital CMS dollars and can protect an ED contract. James Adams, MD, implored the audience at the ACEP Scientific Assembly last year to “own” patient satisfaction scores. The reason is compelling. Low ED patient satisfaction scores correlate with inpatient HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, which is Medicare's mandate to tie patient satisfaction to hospital reimbursement starting in 2015.

Not only do high scores usually reflect good care, but to put it bluntly, it secures an ED group's contract with the hospital, which depends on CMS dollars to stay open and provide medical services for its community.

Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.

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